Should the Discipline of Family Medicine Honor Its Commitment to the Health of the Public by Defining Its Central Mission as “Continuity of Care” or as “Improving Health Outcomes”?

Question

Should the discipline of family medicine honor its commitment to the health of the public by defining its central mission as “continuity of care” or as “improving health outcomes”?

On the surface, this question sounds somewhat naive; however, the increasing fragmentation of care in our health system, combined with a current healthcare focus on discrete, measurable health outcomes for major diseases and conditions does, perhaps for some, elevate this purpose above something as ineffable as promoting longitudinal relationships.

The discipline of family medicine has historically focused on longitudinal patient relationships and continuity of patient care as one of the essential pillars of the discipline and its approach to care. Much has been written about the benefits of continuity in family medicine and primary care.^1–3 Growing corporate involvement in health care and the drive for access and convenience challenge the value of the continuity relationships. In fact, continuity of care is not on the roadmap of many newer initiatives in health care that strictly focus on health outcomes.

Proposition

Family Medicine should focus its public message to patients, communities and policy makers on promising enduring continuity relationships (Raj Woolever, MD, Portsmouth Residency Program Director; President, AFMRD)

Continuity of care has long been a defining feature of family medicine and is explicitly embedded in the specialty’s core values, including the commitment to investing in continuous healing relationships. In family medicine, continuity is not simply a scheduling construct or a measure of visit frequency; it represents an enduring partnership between patient and physician that unfolds over time, across settings, illnesses, and life stages. As healthcare delivery becomes increasingly fragmented and transactional, reaffirming continuity as a central value is both timely and necessary.

Family physicians are uniquely positioned to deliver continuity of care. Unlike episodic or problem-focused specialties, family medicine emphasizes whole-person, relationship-centered care that integrates biomedical, psychological, and social dimensions of health. Sustained relationships allow family physicians to accumulate deep contextual knowledge of family dynamics, cultural background, prior illness experiences, and patient values, all of which meaningfully inform diagnosis and management. This longitudinal understanding enables family physicians to integrate, personalize, and prioritize care in ways that cannot be replicated through isolated encounters.

The evidence supporting continuity of care is robust and particularly relevant to family medicine. Systematic reviews across diverse healthcare systems consistently demonstrate that higher continuity with a physician is associated with lower mortality.^4,5 Importantly, these findings are not confined to a single disease or population, suggesting that continuity manifests its benefit through the broad mechanisms intrinsic to primary care, including trust, accumulated knowledge, improved communication, and coordinated decision-making. In family medicine, where patients frequently present with multimorbidity and undifferentiated symptoms, these mechanisms are especially consequential.

Continuity also aligns closely with stewardship, another hallmark of family medicine. Studies have shown that patients with more extensive continuity of care experience fewer emergency department visits, fewer hospitalizations, and lower rates of potentially avoidable admissions. These outcomes reflect the capacity of family physicians to manage chronic illness proactively, address concerns before they escalate, and reduce redundant testing or referrals. Continuity thus supports high-value care by improving outcomes while moderating costs.^6–8

Critically, the value of continuity is often under-recognized because it is poorly captured by prevailing performance frameworks. Adding up disease-specific quality measures—such as hemoglobin A1C targets, blood pressure thresholds, or screening rates—misses and devalues the higher-level functions of primary care. As Loxterkamp argues, these reductionist approaches fail to account for the essential work of integrating care across conditions, personalizing decisions to individual circumstances, and prioritizing competing needs for people and populations. In family medicine, the work of deciding what matters most now is often more impactful than optimizing any single disease metric. Continuity enables this prioritization by anchoring care in a long-term relationship that recognizes tradeoffs, uncertainty, and patient goals over time.

Beyond measurable utilization and mortality outcomes, continuity is central to the patient experience and professional meaning in Family Medicine. Patients consistently report greater satisfaction, trust, and perceived quality when they have an ongoing relationship with a personal physician. Rebecca Etz and colleagues, in “A New Comprehensive Measure of High-Value Aspects of Primary Care,” highlight the importance of relationship-centered measures that reflect what patients value most. One of these measures, “My doctor and I have been through a lot together,” captures the essence of continuity in family medicine: shared history, mutual trust, and care embedded in relationship rather than transaction.⁹

For family physicians, these continuous healing relationships are also protective. Longitudinal relationships are associated with greater professional fulfillment and may mitigate burnout by reinforcing meaning, connection, and purpose. Fragmented care models that prioritize throughput over relationships risk eroding the very elements that draw many physicians to family medicine.^10,11

Continuity of care is not an optional feature of Family Medicine. It is foundational to its identity and mission. By investing in continuous healing relationships, family physicians deliver care that is safer, more effective, more humane, and more sustainable. As healthcare systems evolve, protecting and strengthening continuity should be recognized as an essential strategy for achieving truly high-value primary care.

Proposition

Family Medicine should commit to improving health outcomes for the major diseases and conditions their patients suffer from, in addition to continuity. (Kate Rowland, MD, MS Rush University)

The purpose of the physician-patient relationship is to make people healthier. Health is at the core of the relationship. Although this is often unspoken, the relationship is not practical or effective without being grounded in the outcome of improved health, and the positive health outcomes of primary care are not possible without a continuity relationship. There is ample evidence that family physicians and other primary care clinicians are effective at improving health outcomes. Family physicians improve blood pressure control and glycemic control for people with type 2 diabetes.¹² In population-level studies, greater numbers of trained PCPs have been associated with a decreased risk of mortality for people with diabetes.¹³ High-quality primary care has been shown to be associated with reduced mortality from cardiovascular disease, especially in marginalized areas.¹⁴ At a population level, more primary care physicians in an area is associated with lower all-cause and cardiovascular disease mortality.¹⁵ However, it is clear that not all primary care is equal, and we cannot assume that the results produced by one practice will be the same as those created by another. Practice models, team-based care, physician training and support, and panel size all matter. Better outcomes are achievable, but continuity alone won’t produce them.^16–20

To be clear, continuity is associated with positive outcomes and should be emphasized far more than it is in the current healthcare environment. Dementia is an informative case study. Dementia appears to be influenced by multiple modifiable factors, including hearing loss, alcohol use, smoking, and social isolation, in addition to major medical conditions such as hypertension, obesity, and diabetes.²¹ Trials have so far been largely inconclusive for primary prevention of dementia in the primary care setting, but as numbers rise, dementia prevention is likely to be an area where the impact of primary care is demonstrated again, due to the impact of primary care on screening for those modifiable risk factors and treatment of chronic medical conditions.²² A 2025 study found a significant reduction in dementia incidence with varicella zoster vaccination, and others have shown similar results from regular influenza vaccination.^23,24 A trusting relationship with a family physician facilitates vaccine uptake.²⁵

These outcomes are associated with primary care offered in communities in a continuity setting by highly trained physicians and clinicians. Relationships with patients are undoubtedly profound, fulfilling, and a key part of what makes family physicians effective as healers and physicians. Yet the physician-patient relationship, like all professional relationships, is defined by its purpose. The relationship is why patients ask for their physician’s opinion of internet research and why family physicians get messages when a grandbaby is born. The relationship is the difference between adopting a health behavior or not; it is the reason diagnoses are made and treatments are accepted. At the same time, no matter the length of the relationship or the continuousness of care, patients do not, often, ask a doctor why the spinning arm in their dishwasher does not work, or why the bathroom sink is draining so slowly. Those questions are best asked of other kinds of professionals, with whom they have other kinds of professional relationships. Every aspect of the physician relationship with patients depends on health being at the center. It frames why patients come in, what is discussed, and expectations of each person in the relationship. The mutual understanding of health and disease establishes why the physician-patient relationship is formed and how the interaction occurs.

Family medicine has historically emphasized the relationship as an outcome on its own. But health cannot be extracted from this encounter without losing the defining criterion of the relationship, and the relationship cannot be extracted without risking the ability to achieve positive health outcomes. Patients come to family physicians expecting to feel better and be healthier, and the general public expects family physicians to contribute better health outcomes.

If family medicine, as a specialty, decides to really throw its weight behind improving health outcomes as a major imperative for the future, society can expect an even more substantial impact on both population-level and individual-level health outcomes. The specialty will have gained an understanding of the aspects of the relationship that must be preserved to retain that litany of positive community and individual health benefits.

Conclusion

Perhaps the most profound takeaway from this debate is the ambivalence it generated. When asked if the specialty should commit to improving health outcomes for major conditions in addition to committing to continuity relationships, the leaders of major family medicine organizations, representing family medicine excellence in clinical, educational, advocacy, and research endeavors, split the vote roughly 50-50.

Family medicine has long valued the continuity relationship. It is a foundational aspect of the specialty. Family medicine must continue to ask the question: if the physician-patient relationship is as strong and satisfying as can be measured in every possible metric, and by every unmeasurable assessment, but health outcomes are poor, have we fulfilled our contract to society? An evenly split vote is difficult to interpret; perhaps the message that our family medicine leaders sent with their votes was that it is hard to declare whether relationships and outcomes can be split and valued individually.